- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $3,630.78
| Facility | | $2,454.71 | $2,454.71 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,467.37 / $3,981.07
| Professional | | $2,630.27 | $3,467.37 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,981.07 / $3,981.07
| Professional | | $2,951.21 | $3,981.07 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.59 / $707.95 / $6,606.93
| Facility | | $323.59 | $707.95 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $812.83 / $9,549.93
| Professional | | $489.78 | $812.83 | $9,549.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $3,630.78 / $5,248.07
| Facility | | $794.33 | $3,630.78 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $3,090.30 / $3,630.78
| Professional | | $389.05 | $3,090.30 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $407.38 / $4,073.80
| Professional | | $173.78 | $407.38 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $316.23 / $371.54 / $2,754.23
| Facility | | $316.23 | $371.54 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $2,089.30 / $3,630.78
| Professional | | $1,230.27 | $2,089.30 | $3,630.78 |